NURSING CARE PLAN

Patient’s Name : __________________________________________________ Hospital No. : _____________________________________

Age : __________________________________________________ Room No. : _____________________________________

Impression/Diagnosis: ______________________________________________ Physician : _____________________________________

Nurse’s Name & Signature: __________________________________________

CLINICAL PORTRAIT PERTINENT DATA

 NURSING CARE PLAN
CUES NURSING SCIENTIFIC BASIS GOALS & OUTCOME NURSING RATIONALE OF EVALUATION
DIAGNOSIS CRIETERIA ACTIONS & NURSING ORDERS
NURSING ORDERS

Subjective Acute pain related Severe systemic manifestation After 2-4 hours of Independent: -Indicates need
“Sakit to tissue trauma of trauma involving soft comprehensive nsg -assess pain for/effectivenessof
akongkinatawhan ” secondary to NSVD tissue,principally skeletal intervention,measures reports,noting interventions and
as verbalized by the muscle, due to pronlonged to alleviate pain will location,pain may signal on
patient severe crushing.it leads to be implemented scale,frequency development of
increased permeability of the and onset.Note complications.
cell membrane and to release of To minimize non-verbal cues
Objective the potassium,enzymes,and complication of vaginal
myoglobin from within pain and intervene as -encourage a pt. -efficacy of
Patient with lumbar cells:which results in acute pain. early as possible To report pain as comfort measures
pain:pain scale-2 (www.wfongdiagnosis.com/med develops and medication is
ical/ -Pt. Pain will reduced improved in timely
Patient at bed rest Tissue _trauma.htm) from a pain scale of 2 intervention
to 0.
-encourage -can reduced
-Pt.will show signs of verbalization of anxiety and fear
comfort and alleviation feelings and thereby
of pain is relieved reduced
Demonstrate of use perception of
relaxation skills of intensity of pain
diversion activites.

-perform -promotes
palliative relaxation
measures e.g back decreases muscle
massage,repositio tension
ning
Collaborative -Provide relief of
-administer pain and
mefenamic discomfort,PCA
acid,analgesic,or medication keeps
pain killers.used the blood level of
pt controlled analgesia
analgesia or stable,preventing
provide around cyclic
the clock undermedication
analgesia with or overmedication
rescue doses PRN